TennCare bill emerges in Legislature
NASHVILLE (AP) — The bill authorizing Gov. Phil Bredesen’s proposed TennCare changes provides a safety valve for people who need more health care than available through the new limitations, but makes clear those exceptions are not an entitlement.
The bill’s language is an apparent attempt to forestall court decisions that have impacted the program in the past.
The proposed new law was presented in the Legislature for the first time Tuesday. It was discussed briefly in a House subcommittee and deferred until Wednesday.
The bill is on target with the governor’s stated goal of putting a tighter rein on the $7.3 billion program. Not all of its provisions have been fully discussed, but already there are concerns among advocates for enrollees and health care providers.
Bredesen proposes limiting drug prescriptions to six per month; hospital visits to 45 inpatient and eight outpatient visits per year; doctor visits to 10 a year; and laboratory or X-ray procedures to 10 a year. Those are now unlimited.
“We have talked to doctors and there are few who feel these hard limits are good medical practice,” said Tony Garr of the Tennessee Health Care Campaign, which advocates for TennCare enrollees. “You don’t want that seventh prescription or 11th doctor’s visit to be a trip to the emergency room.”
Bredesen said Monday he is well aware of the impact lawsuits have had previously TennCare, and the possibility of more to come, including challenges to the benefit limits.
“I don’t know where they’ll come from,” the governor said. “We’re making fundamental changes to a $7 billion program. I certainly hope people will be sensible, but we’d be crazy not to prepare ourselves for that as one of the possibilities.”
Finance Commissioner Dave Goetz, whose department oversees TennCare, said the administration “is trying to be thoughtful and careful so we’re defensible in court, and so we can do what we say we’ll do.”
The bill proposes to set up the TennCare Foundation. It would be funded on an annual basis through the budget process and pay for services beyond the set limits — like when an enrollee needs seven or eight prescriptions per month to stay in the work force or to stay out of the hospital.
The bill is explicit that no enrollee is entitled to those additional benefits. There is no right of appeal for denials of care, and the bill notes there may not be enough money to satisfy all applicants.
Mike Huggins of the Tennessee Hospital Association said the state’s hospitals are concerned “as to what ultimately might occur in terms of unreimbursed care.”
The worry is that benefit limits could return the health care situation to where it was under the old Medicaid system, where doctors and hospitals were inundated with charity care and the entry point to the health care system was often the emergency room.
People on all sides of the discussion are generally supportive of the strengthened fraud and abuse provisions in Bredesen’s proposal. Those include creation of the Office of the Inspector General for TennCare, who will be given broad authority and funding to pursue people who improperly receive — or provide — benefits.
Russ Miller of the Tennessee Medical Association said he had concerns that the bill seems to put more responsibility for policing fraud on doctors and none on managed-care organizations.
“We’ve heard concerns from doctors about the increased risk to their practice, but without seeing the full details we don’t know,” he said.
He said the TMA plans to meet with Bredesen and other administration officials next week to discuss the plan.
“This program needs to be tightened up,” Miller said. “It’s something we’ve called for since its inception. Generally, we agree with what he’s doing and we agree this is the last hurrah for TennCare, and these are all necessary elements.”
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On the Net:
Tennessee General Assembly: http://www.legislature.state.tn.us/
State government: http://www.Tennessee.gov